Monthly Archives: December 2014

Dr. Groopman Discovers the Swamp

IMG_0330 December 15

On a sweltering morning in June, 1976, Jerome Groopman, a newly graduated MD, put on his starched white coat, placed a stethoscope in his black bag, and reported for duty.  At the time, he wasn’t fully aware that he was entering a swamp.  He soon found out!

He had spent the previous four years of medical school becoming a doctor, which included endless hours in the classroom studying anatomy, physiology, pharmacology and pathology from textbooks and manuals, and more endless hours “playing doctor:”  learning how to take a patient’s history, how to do a physical examination; and how to think about making diagnoses of their illness.  Until this July morning, however, he never had complete responsibility for the well-being of a patient.

This is not to say that his years in the classroom were easy or simple.  ”Throughout those…years of medical school,” writes Groopman, “I was an intense, driven student, gripped by the belief that I had to learn every fact and detail so I might one day take responsibility for a patient’s life.”

Each day, he later wrote,

I sat in the front row in the lecture hall and hardly moved my head, nearly catatonic with concentration…determined to retain everything. I scribbled copious notes during the lectures and after bedside rounds. Each night I copied those notes onto index cards that I arranged on my desk according to subject. On weekends I would try to memorize them. My goal was to store an encyclopedia in my mind, so that when I met a patient, I could open the mental book and find the correct diagnosis and treatment.

His learning experiences during those intense and difficult years, while different in many ways, were alike in that the questions he pondered over and problems he struggled with almost always ended with a correct answer or a right solution.

Now, on the first day of his internship  at the Massachusetts General Hospital, he began the “real thing.” As he described it, it was “The end of play-acting as a doctor and the start of being a real one.” He was about to see real patients with real illnesses.

As he stood before the door of one his new patients, Groopman was beginning a major transition in his professional life:  He was leaving  the high, hard ground of academic preparation and entering the swamp-like environment of clinical practice.  Before knocking on the door of the patient in room 632, Groopman touched his left jacket pocket and felt the pack of index cards from medical school.  The cards,  he told himself, “would provide the ballast to keep me afloat alone.”

Groopman had studied the medical records of the patient in room 632 and learned that his name was William Morgan, a 66 year-old African-American man with a history of  hypertension.  He knocked on the door and heard “come in” from inside the room.

Groopman opened the door and said “Good evening Mr. Morgan, I am Doctor Groopman, your new intern.”

“First day, huh?” said Mr. Morgan with a grin.

After a few moments of pleasant small talk, Groopman was saying goodbye when suddenly, with no warning, “Mr. Morgan shot upright in bed.  His eyes widened.  His jaw fell slack.  His chest began to heave violently.”

“What’s wrong, Mr. Morgan?”  Groopman shouted.

“He shook his head, unable to speak, desperately taking in breaths.”

Groopman was paralyzed with shock and fear.  He was unable to think.  The encyclopedia of knowledge he had so laboriously constructed had vanished.  ”My palms became moist,” he wrote, “my throat dry.  I couldn’t move.  My feet were fixed to the floor.”  When for the first time Groopman was faced with a crisis – a life or death situation – he had no idea what to do.

Suddenly he heard a deep voice behind him.  ”This man seems be in distress.”

The voice was that of John Burnside, an experienced cardiologist who happened to be passing the door and heard the commotion inside.  Deftly, with no hesitation, he reached into Groopman’s pocket, took out the stethoscope, placed it over Morgan’s heart, listened for a few seconds, then handed it to Groopman.  ”Here. Listen.”

“I heard something that sounded like a spigot opened full blast,” wrote Groopman,” then closed for a moment, and opened again, the pattern repeated over and over.”   In his training, he had listened to hundreds of hearts beating in hundreds of chests and had never heard anything like this.  It made absolutely no sense to him.

But Burnside knew:  ”This gentleman just tore through his aortic valve.  He needs the service of a cardiac surgeon.  Pronto.”

While Burnside stayed with Morgan, Groopman raced to find a nurse.  Within minutes he returned with the duty nurse who had the resuscitation cart in tow.  Other nurses arrived.  Then the cardiac surgery resident appeared, and together they rushed Morgan to the OR.

Later, after the crisis was over, Groopman sat in a daze.  ”The event seemed surreal,” wrote.  ”I was enjoying a first conversation with one of my patients, then, like an earthquake, Mr. Morgan’s sudden upheaval, then the deus ex machina of Dr. Burnside.  I felt the weight of  the cards in my pocket.  Straight A’s when I was a student, play – acting.  Now, in the real world, I gave myself an F.”

Doing a” Groopman”

At one time or another, Groopman’s experience is one we all share when we attempt to apply the knowledge and skills we learn in the classroom to the real world:  Straight A’s (or at least good grades) in the classroom and F’s when we try to put into practice what we have learned.   Most of our preparation for doing difficult and complicated work is done on the high, hard ground of theory and textbook where we find answers in the back of the book and are taught solutions that others have already discovered.  Even when part of our preparation includes occasional visits to the swamp to see what it’s like, we usually just dip our toes in, never going in all the way.   It is only after we have “graduated” that we are fully responsible for doing Real Work.

The first times we face complicated, messy situations for which we have responsibility in situations that are important and that demand that someone take immediate action,  we often end up doing a “Groopman:”  Stuck in place,  ”feet fixed to the floor, palms moist, throat dry, paralyzed with shock and fear.”

Doing a “Burnside”

All of us will spend time in our lives on both the high, hard, ground and in the swamps.  Almost all  of our classroom education prepares us to work and live on the high ground;  rarely are we prepared for what awaits us in the swamp.  Success in the swamp – acting with confidence and competence as we grapple with wicked problems – requires us to learn how to do a “Burnside:”  Show up in the middle of the storm fully present and alert with a calm and confident manner; get down into the mud and muck;  begin the process of figuring out what is happening; recruit and enlist others to work with us;  formulate an idea of the problem; then move, taking appropriate action to deal with the newly defined situation.

Becoming a Swamp Master 

It is clear from Groopman’s account that Burnside was a “Swamp Master:”  He knew where to start, how to make sense of what was happening, and what to do when he defined the problem. If he had been wrong in his first diagnosis, he would have tried something else, and then something else after that.  Burnside’s sudden and unexpected appearance with his calm, purposeful response to Mr. Morgan’s crisis can give us confidence that it is possible to not only  survive in the swamp,  but to do Good Work there, and even to flourish.

In a world full of wicked problems, our challenge is to become a Swamp Master!

Becoming a “swamp master” means,  at a minimum, the following: Understanding the differences between high ground and swamp; becoming reasonably comfortable amid the  muck and the chaos and the “hurly- burly” of the swamp; being fully aware that different rules apply; possessing the skills of gathering information about the “mess;”  making sense of it in order to determine the nature of the problem;  having the ability to involve others in collaborative work;  identifying and defining “a problem;”  giving it a name;  working with others to put together an action plan; then going to work to make a difference.

While there are different degrees of “Swampness,” all the way from mild encounters to major crises, any journey toward becoming a Swamp Master will require one to pass through these stages of  learning:

 Survival;

Muddling Through;

Coping;  

Managing;

Flourishing.

It is not an easy road.  Not everyone who takes it is successful.  Many people find themselves stuck in one stage or another, most often the stage of  Muddling Through.

What’s more, the road to becoming a Swamp Master is one that has no end.  Each time we enter a new “swamp” situation, we find ourselves back at Survival Mode, starting over.  There are, however, insights, approaches and skills that we can learn along the way and then take with us as we struggle, skills and insights that will provide us with huge advantages as we make our moves from Surviving to Flourishing.  We can learn to become Swamp Masters!

 

 

 

 

The High, Hard Ground and the Swamp

L1000486   December 1

In the Land of Opportunity, Achievement and Despair where professional people spend their working days, there is a high, hard ground and a swamp.  On the high, hard ground there is firm footing, good light, and useful, effective tools with which to work. Conditions in the swamp are dramatically different:  There is no firm place to stand and people feel they are in over their heads; the light is bad – dark, gloomy and uncertain; and the tools that most people bring with them are either inappropriate or obsolete for the work that must be done.

High Ground

On the high ground there is a sense of order and predictability.  The rules are mostly explicit and clear, and the roles people play in working on their problems are defined by education, training, and seniority.

Swamp

In the swamp things are in a perpetual mess.  As the poet John Keats put it, “There is nothing stable…; uproar’s your only music.”  The rules of engagement are murky and shifting, and the sources of legitimacy for the roles that are available are confusing.

High Ground

People who work on the high ground usually work in comfortable settings.   They are well educated, well paid, and well respected.  Interactions between them tend to be characterized by an atmosphere of civility and mutual respect, at least on the surface.   To use T. S.  Eliot’s illuminating image, people come and go “talking of Michelangelo.”

Swamp

People in the swamp may be well educated, but they are rarely well paid or well respected.  The work is messy, frustrating, and often painful.  Civility and respect are liable to be in short supply.  People frequently divide into factions and define each other as “”the enemy.”  They are constantly preoccupied by such questions as “How are we going to survive?” “How can we get those bastards?” and “When will we get a break?”

High Ground

The people who spend their working lives on the high ground bring specialized and expert knowledge to their work.  They are mostly scientists, engineers, technologists,  researchers, and skilled and experienced technicians. The work they do is usually theory-based, and often leads to hypotheses about causes and relationships.  These hypotheses are then tested by gathering data using quantitative methods, expressed in numbers, and organized into tables and charts. Many of their “recommended solutions” to the problems they struggle with emerge from their efforts as reports, studies or academic papers containing suggestions and recommendations as to what needs to be done.

Swamp

Down in the swamp there are no “experts” who can tell others what to do.  Everyone is struggling to figure out what is happening and what should be done.   Those who can make the best case – and at times this means those who make the most outlandish promises or who shout the loudest – gain influence, while those who hold back tend to be ignored.  Rather than formulating hypotheses to be tested, resulting in the generation of substantive information, swamp people rely upon hunches, intuition, beliefs and faith in order to make their case. When data do appear in the swamp, it is often ignored or distorted.

High Ground

The problems that are addressed on the high ground are problems that can be solved.  As Nobel Prize winner P. B. Medawar observes,  ”Good scientists study the most important problems they think they can solve. It is, after all, their professional business to solve problems, not merely to grapple with them.”

Swamp

Down in the swamp, the people’s business is grappling with problems, not solving them (since that’s often impossible).  People working in the swamp do not get to choose which problems they want to work on, but must take on the problems that are assigned or that they encounter on their own.

High Ground

While the “high ground” problems are often new, and sometimes even mysterious, the methods for working on them are generally well known.  People know where and how to begin; they are confident that the methods they have been trained to use will yield positive results.  When positive results do not appear, they move on to more promising prospects.

Swamp

In the swamp, all problems are new and mysterious.  While there are some important principles which can provide guidance (“Don’t look for a solution until you a have a deep understanding of the problem.”  ”One person alone cannot hope to understand what is really happening.”), what is called for is improvisation, experimentation, and provisional tryouts.  ”Do something,” said the American artist Jasper Johns, “then do something to that, then something to that, and eventually you’ll have something.”

High Ground

While the people on the high ground are good at writing recommendations and making reports, most never actually attempt to put into practice their own recommendations. They leave this to others.

Swamp

Those who work down in the swamp are responsible for not only deciding what to do, but also for doing it!  If anything is to be accomplished, they are the ones who must do it.

High Ground

When the people who work on the high ground experience failure, they are not punished.  Failed experiments are seen as necessary steps toward success.  When an important problem is “finally solved,” then honor, glory and financial payoffs follow.

Swamp

When it comes to the rewards of working in the swamp, things are grimmer. No rewards are given for failed attempts, and since the problems that people must grapple with never get solved, recognition, honor and glory are rare.  As a result, those who expect that “solutions” to fix important problems will emerge from the swamp are perennially disappointed.  People who spend their working lives in the swamp must be content with the personal satisfaction of having done Good Work.

Where Shall We Work?

After discussing the different  challenges to be found on the high, hard ground and in the swamp in The Reflective Practitioner, Donald A. Schon asks the critical questions:  Shall we stay on the high, hard ground where “the problems…however great their technical interest, are often relatively unimportant…to the larger society, while in the swamp are the problems of greatest human concern?  Or shall [we] descend to the swamp where [we] can engage the most important and challenging problems?”

His questions cuts to the core:  Where will we choose to work, and what kind of problems will we tackle?

Been There, Done That!

Schon’s questions, while important, are rhetorical:

First, because no matter one’s professional or vocational choice, eventually we all find ourselves in one swamp or another.  Those who spend most of their working days on “high ground” must eventually leave the lab or the office and go to a meeting where people are engaged in activities of a very different nature: They are talking, and often arguing, about prospects, policies and practices, and they are engaged in the very tough work of making difficult decisions about which directions to take.  Because the issues are complicated and because the behaviors of the people discussing the issues are often erratic, emotional, irrational, and self-serving,  these meetings are swamp-like.  While they may be referencing data and recommendations from “high ground” reports and research studies, the data and recommendations themselves neither make decisions nor resolve problems.  In fact, the data and recommendations are often distorted or ignored.  Making decisions is the work of human beings, each of whom brings to the table their prejudices, preferences, beliefs, values, and biases.

A second reason Schon’s question is rhetorical – “…shall [we] descend to the swamp where [we] can engage the most important and challenging problems?” – is because we are already there!   We regularly “descend” down to one kind of a swamp or another:  We struggle with complicated personal decisions and choices; we despair over family relationships that never seem to get solved; we find ourselves in serious conflict with bosses and colleagues at work; we struggle to hold together some of our important relationships; we face issues that are not “Right vs. Wrong,” but “Right vs. Right,” where both sides of an issue have legitimate claims. We are well acquainted with swamps!

From High Ground to Swamp and Back

Situations turn into swamps when we find ourselves confronting important and complicated situations and issues that are rapidly changing; that are confusing and complex; that often consist of a “damned if you do and damned if you don’t” dilemma; that involve other people who not only hold strong opinions and preferences that are quite different from our own,  but seem unwilling to discuss them, let alone work together to make things better;  where many of these people lack the knowledge, experience, or skills that could be helpful;  and no matter what we do with these problems, they refuse to get resolved once and for all.

We have all spent time in swamps, and we will find ourselves continuing to muck around in them in the future.  Three questions are important:  ”How can we survive in the swamp?”  ”How can we make sense of what is happening there?” and “How can we get out?”  In the coming weeks I will address each of these questions.  Stay tuned!

 

 

 

 

 

.